title: Residual shunting after percutaneous PFO closure: how to manage and how to close.
abstract: BACKGROUND
  Initial transcatheter Percutaneous patent foramen ovale (PFO) closure attempt may be incomplete and result in persistent residual shunting. The optimal treatment strategy for these patients remains unknown.
  
  
  METHODS
  Twenty-seven patients were diagnosed to have a moderate-large residual shunt at least 12 months after initial PFO closure associated or not to a recurrent ischemic event and underwent a second procedure. Residual shunt characteristics were classified in two types: Type I: tunnel-like or between the disk defect (11 patients); Type II: accessory defect next to a device rim or accessory defect (16 patients).
  
  
  RESULTS
  Fourteen subjects had a recurrent transient ischemic attack/stroke (52%). Median time between the first and the second PFO closure procedure was 17 months (range 12-60 months). Deployment of a second device was successful in 92% (25/27) patients. A Type I defect was closed by using a coil or Amplatzer Vascular Plugs. In two patients a surgical option was chosen as a first option. A Type II defect was closed by using a double disc device. At a median follow-up of 36 months (range 12-60 months), two subjects showed significant residual shunting between the two disks of the device (Type I) at 12 months follow-up and were sent to surgery.
  
  
  CONCLUSIONS
  Significant residual shunts can be successfully closed by using a second device. Care is required to select an optimal device depending on anatomy and original device. In some subjects, lack of endothelial covering account for the persistence of a significant residual shunting.
authors.affiliation: Pediatric cardiology and GUCH Unit, Policlinico San Donato IRCCS, 20097, San Donato Milanese, Italy.
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Butera
authors.forename: Javier Fernandez
authors.initials: JF
authors.lastname: Sarabia
authors.forename: Antonio
authors.initials: A
authors.lastname: Saracino
authors.forename: Massimo
authors.initials: M
authors.lastname: Chessa
authors.forename: Luciane
authors.initials: L
authors.lastname: Piazza
authors.forename: Mario
authors.initials: M
authors.lastname: Carminati
mesh_terms: D000328:Adult; D000368:Aged; D006328:Cardiac Catheterization / Q000009:adverse effects* / Q000295:instrumentation; D002560:Cerebrovascular Circulation; D019560:Echocardiography, Three-Dimensional; D017548:Echocardiography, Transesophageal; D005260:Female; D054092:Foramen Ovale, Patent / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D002546:Ischemic Attack, Transient / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D012008:Recurrence; D055989:Septal Occluder Device; D020521:Stroke / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
keywords: cardiac catheterization; cryptogenic stroke; patent foramen ovale; transcatheter closure